Understanding and Managing Diarrhoea in Children

Diarrhoea remains one of the most significant health threats facing children worldwide. Despite being both preventable and treatable, this condition continues to claim hundreds of thousands of young lives each year, particularly in developing countries. For nursing professionals, understanding the types, causes, and management strategies for childhood diarrhoea is essential for providing effective patient care and educating families about prevention and treatment.

What is diarrhoea and why is it dangerous for children? 🔗

Diarrhoea is defined as the passage of three or more loose or liquid stools per day, or more frequently than is normal for an individual. It’s important to note that frequent passing of formed stools does not qualify as diarrhoea, nor does the passing of loose, pasty stools by breastfed babies, which is entirely normal.

The condition is typically a symptom of gastrointestinal infection caused by various bacterial, viral, and parasitic organisms. According to the World Health Organization, diarrhoeal disease is the third leading cause of death in children aged 1-59 months, killing approximately 443,832 children under five annually. This translates to over 1,200 young children dying each day from a condition that has a simple and cost-effective treatment solution.

Children in low-income countries under three years old experience an average of three diarrhoeal episodes every year. Each episode deprives them of essential nutrition needed for growth, creating a dangerous cycle where diarrhoea causes malnutrition, and malnourished children become more vulnerable to future episodes. South Asia and sub-Saharan Africa account for more than 80 per cent of child deaths due to diarrhoea globally.

Types of diarrhoea in children 🔗

Understanding the classification of diarrhoea helps healthcare providers determine the appropriate treatment approach and identify potentially serious cases.

Acute watery diarrhoea 🔗

This is the most common type, lasting several hours to a few days. It includes cholera and is usually caused by viral or bacterial infections. Most childhood diarrhoeal diseases resolve within the first week of illness, making acute watery diarrhoea generally self-limiting with proper supportive care. The primary concern is preventing and treating dehydration during the episode.

Dysentery (acute bloody diarrhoea) 🔗

Dysentery presents with blood in the stool and is typically caused by bacterial pathogens such as Shigella. This type requires more aggressive management, including antibiotic therapy. Antibiotics should be given for children with bloody diarrhoea (probable shigellosis) and suspected cholera with severe dehydration. Healthcare providers should treat for Shigella first and then for amoebiasis if laboratory examination is not possible.

Persistent diarrhoea 🔗

Persistent diarrhoea lasts 14 days or longer and is particularly concerning in children under two years, especially during summer months. This type requires thorough evaluation to identify underlying causes, which may include intestinal infections, malabsorption issues, or in HIV-infected children, could indicate stage 3 HIV infection. Persistent diarrhoea in HIV-positive children is associated with significantly higher mortality rates and requires specialized management.

Common causes and pathogens 🔗

Infection is the primary cause of childhood diarrhoea, with pathogens spread through contaminated food, drinking water, or person-to-person contact due to poor hygiene.

Viral pathogens account for up to 90% of diarrhoeal cases in children under five years. Rotavirus, norovirus, and adenovirus are the most common viral causes. Rotavirus was recognized by 1980 as the most common cause of severe gastroenteritis in infants and young children, and before vaccines became available, it was responsible for up to 500,000 deaths among children annually worldwide.

Leading bacterial pathogens include Escherichia coli, non-typhoidal Salmonella, Shigella, and Vibrio parahaemolyticus. While bacterial and viral gastroenteritis cannot be definitively distinguished on clinical grounds alone, bloody mucoid diarrhoea and high fever are more commonly associated with bacterial infections.

Parasitic pathogens such as Cryptosporidium, Giardia, and Entamoeba species are prevalent in children aged 3-5 years and are more common in developing countries during summer months.

Understanding and assessing dehydration 🔗

The most severe threat posed by diarrhoea is dehydration. During a diarrhoeal episode, water and electrolytes including sodium, chloride, potassium, and bicarbonate are lost through liquid stools, vomit, sweat, urine, and breathing. Dehydration occurs when these losses are not adequately replaced.

The WHO classifies dehydration into three levels:

Severe dehydration: Characterized by at least two of these signs: lethargy or unconsciousness, sunken eyes, inability to drink or drinking poorly, and skin pinch that returns very slowly (≥2 seconds). This is a medical emergency requiring immediate intravenous fluid therapy.

Some dehydration: Identified by two or more signs including restlessness or irritability, sunken eyes, and drinking eagerly or appearing thirsty. These children require oral rehydration therapy in a supervised setting.

No dehydration: When there aren’t enough signs to classify as some or severe dehydration. These children can be managed at home with continued feeding and increased fluids.

Hypernatremic dehydration is more common in well-nourished children and those infected with rotavirus, presenting with irritability, increased thirst disproportionate to clinical dehydration, and skin that feels doughy. This requires specific rehydration approaches.

The three pillars of diarrhoea management 🔗

The three essential elements in managing all children with diarrhoea are rehydration therapy, zinc supplementation, and counselling for continued feeding and prevention.

Oral rehydration therapy (ORT) 🔗

Oral rehydration solution (ORS) should contain a combination of glucose and sodium to take advantage of the sodium-glucose cotransport in the gut and improve absorption. This mechanism makes ORT a cost-effective method for managing acute gastroenteritis and reduces hospitalization requirements in both developed and developing countries.

For children with some dehydration, parents should administer 50-100 ml/kg over four hours, using a spoon or syringe every minute or two. For each diarrheal stool, an additional 10 mL/kg (up to 240 mL) should be given. Vomiting usually should not deter oral rehydration therapy because it typically abates over time when small, frequent amounts are given.

Children with severe dehydration require intravenous fluid therapy initially, with ORT introduced once their condition stabilizes.

Zinc supplementation 🔗

Zinc is an important micronutrient lost in greater quantities during diarrhoea. Zinc supplements reduce the duration of a diarrhoea episode by 25% and are associated with a 30% reduction in stool volume. A 10-14 day supplemental treatment course of dispersible zinc tablets shortens diarrhoea duration and improves outcomes. This replacement also helps the child’s recovery and lowers the incidence of diarrhoea in the following 2-3 months.

Continued feeding 🔗

During diarrhoea, decreased food intake and nutrient absorption combine with increased nutrient requirements to cause weight loss and failure to grow. The vicious circle of malnutrition and diarrhoea can be broken by giving nutrient-rich foods during and after the diarrhoea episode.

Breastfed children should continue breastfeeding frequently throughout the episode. During the initial 4-hour rehydration period, no food except breast milk should be given. After 4 hours, if the child still has some dehydration, food should be given every 3-4 hours while continuing ORS.

What not to do: avoiding harmful practices 🔗

‘Antidiarrhoeal’ drugs and anti-emetics should not be given to young children with acute or persistent diarrhoea or dysentery. These medications do not prevent dehydration or improve nutritional status, and some have dangerous, sometimes fatal side effects. Antimotility drugs may be harmful, especially in children under 5 years of age, as they temporarily reduce symptoms but delay elimination of organisms causing the diarrhoea and may prolong the illness.

Antibiotics should only be used for specific indications such as bloody diarrhoea, suspected cholera with severe dehydration, and other serious non-intestinal infections. Routine use of antimicrobials is not recommended.

Prevention strategies 🔗

Prevention is always preferable to treatment. Almost 60 per cent of deaths due to diarrhoea worldwide are attributed to unsafe drinking water and poor hygiene and sanitation. Handwashing with soap alone can reduce the risk of diarrhoea by at least 40%.

Rotavirus vaccination 🔗

The rotavirus vaccine provides protection against one of the most common causes of childhood diarrhoea-related death. Two types of vaccines are available: RotaTeq given in three doses at 2, 4, and 6 months of age, and Rotarix given in two doses at 2 and 4 months. These vaccines are considered 74% effective or better in preventing rotavirus infection and 96% or better for preventing serious illness.

The first dose should be given before 15 weeks of age, and all doses must be completed by 8 months of age. About 9 out of 10 vaccinated children are protected from severe rotavirus disease.

Breastfeeding and nutrition 🔗

Exclusive breastfeeding for the first six months of life is protective and prevents diarrhoea from occurring in young children. Breastfeeding also reduces the severity of diarrhoea when it does occur. High-dose vitamin A supplementation helps maintain strong immune systems and can reduce cases of diarrhoea by 15%.

Educating caregivers 🔗

Nursing professionals play a crucial role in educating mothers and caregivers about home management of diarrhoea. Key messages should include: increasing fluids, giving zinc supplements, continuing to feed the child, and recognizing warning signs that require immediate medical attention.

Warning signs include: passage of many watery stools, repeated vomiting, becoming very thirsty, eating or drinking poorly, developing a fever, blood in the stool, or not improving within three days. These require prompt consultation with a health worker.

What do you think? How can nursing professionals better support families in preventing childhood diarrhoea in communities with limited access to clean water? What role do you think community-level health education programs play in reducing diarrhoea-related mortality?

References

1. https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease
2. https://data.unicef.org/topic/child-health/diarrhoeal-disease/
3. https://pmc.ncbi.nlm.nih.gov/articles/PMC8804427/
4. https://www.ncbi.nlm.nih.gov/books/NBK154434/
5. https://www.who.int/health-topics/diarrhoea
6. https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-19-rotavirus.html
7. https://www.worldgastroenterology.org/guidelines/acute-diarrhea/acute-diarrhea-english
8. https://www.merckmanuals.com/professional/pediatrics/dehydration-and-fluid-therapy-in-children/oral-rehydration-therapy
9. https://www.acep.org/pediatrics/resources/resource-articles/oral-rehydration-therapy
10. https://www.cdc.gov/rotavirus/vaccines/index.html
11. https://www.mayoclinic.org/diseases-conditions/rotavirus/symptoms-causes/syc-20351300